Fellow: Kris Chang, DO | The University of Texas at Austin Dell Medical School, Dell Children’s Medical Center
Article: Kahn D, Stewart E, Duncan M, et al. A Prescription for Note Bloat: An Effective Progress Note Template. J Hosp Med. 2018; 13(6): 378-382.
Summary: As hospitals in the United States have adopted electronic health records (EHRs), there has been concern that the quality of documentation has suffered. The authors conducted a prospective quality improvement study across four internal medicine residency programs (UCSF, UCSD, UCLA, University of Iowa) to determine if a bundled intervention consisting of didactic teaching and an electronic progress note template improved note quality, length and timeliness. Two hundred pre-intervention notes and 199 post-intervention notes written by intern physicians on inpatient internal medicine rotations were graded by three different internal medicine faculty using a validated physician documentation quality instrument (PDQI-9), a questionnaire based on the ACGME competency note checklist, and a general impression score tool designed by the task force. There were significant improvements seen in all domains of the PDQI-9, 6 of 13 note competency items, and the general impression score. Notes were signed about 1.3 hours earlier and had approximately 25% fewer lines.
Key Strengths: The study had a relatively large sample size as it spanned four different academic institutions. It also used three different note assessment tools, all of which showed improvement with their bundled intervention. Additionally, the study showed that by removing “efficiency functions” such as auto-population and copy-forward, note writing could be made more efficient.
Limitations: As this study was unblinded, there may have been bias and falsely elevated post-intervention scores. Additionally, there was poor interrater reliability. The pre-intervention and post-intervention notes were graded at different points in the same academic year, and thus, it is difficult to distinguish between improvements due to intern maturation versus the bundled intervention versus other factors. For instance, UCSD had low note template use (21%) though still had significant improvement in the general impression score, and University of Iowa had relatively high note template use (79%) though no significant improvement in the general impression score.
Major Takeaway: Educating residents on documentation and providing an EHR template that incorporates best practices can improve note quality, decrease note length, and allow for earlier completion of notes. With notes completed earlier in the day, residents could potentially have more time to attend to patients, hand-offs, and improve patient safety overall.
Impact on Practice: This study provides possible interventions any residency program can use to improve their progress notes. After reading this article, we have formed a “Note Bloat” workgroup in which we aim to develop our own best practices for clinical documentation. Future steps include developing similar interventions to history and physicals or discharge summaries.
Article: Kahn D, Stewart E, Duncan M, et al. A Prescription for Note Bloat: An Effective Progress Note Template. J Hosp Med. 2018; 13(6): 378-382.
Summary: As hospitals in the United States have adopted electronic health records (EHRs), there has been concern that the quality of documentation has suffered. The authors conducted a prospective quality improvement study across four internal medicine residency programs (UCSF, UCSD, UCLA, University of Iowa) to determine if a bundled intervention consisting of didactic teaching and an electronic progress note template improved note quality, length and timeliness. Two hundred pre-intervention notes and 199 post-intervention notes written by intern physicians on inpatient internal medicine rotations were graded by three different internal medicine faculty using a validated physician documentation quality instrument (PDQI-9), a questionnaire based on the ACGME competency note checklist, and a general impression score tool designed by the task force. There were significant improvements seen in all domains of the PDQI-9, 6 of 13 note competency items, and the general impression score. Notes were signed about 1.3 hours earlier and had approximately 25% fewer lines.
Key Strengths: The study had a relatively large sample size as it spanned four different academic institutions. It also used three different note assessment tools, all of which showed improvement with their bundled intervention. Additionally, the study showed that by removing “efficiency functions” such as auto-population and copy-forward, note writing could be made more efficient.
Limitations: As this study was unblinded, there may have been bias and falsely elevated post-intervention scores. Additionally, there was poor interrater reliability. The pre-intervention and post-intervention notes were graded at different points in the same academic year, and thus, it is difficult to distinguish between improvements due to intern maturation versus the bundled intervention versus other factors. For instance, UCSD had low note template use (21%) though still had significant improvement in the general impression score, and University of Iowa had relatively high note template use (79%) though no significant improvement in the general impression score.
Major Takeaway: Educating residents on documentation and providing an EHR template that incorporates best practices can improve note quality, decrease note length, and allow for earlier completion of notes. With notes completed earlier in the day, residents could potentially have more time to attend to patients, hand-offs, and improve patient safety overall.
Impact on Practice: This study provides possible interventions any residency program can use to improve their progress notes. After reading this article, we have formed a “Note Bloat” workgroup in which we aim to develop our own best practices for clinical documentation. Future steps include developing similar interventions to history and physicals or discharge summaries.